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Laurel Creek Health Center

2800 Estates Dr., Fairfield, CA 94533 · Non profit - Corporation · 60 certified beds · (707) 432-1200 Medicare only — no Medicaid

Call the home — (707) 432-1200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation$35,493 in federal fines
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (29% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $35,493 in federal fines (most recent 2024-04-03)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3700 Hilborn Rd · (707) 422-0900 · Call to confirm hours
Pharmacy
3340 N Texas St · (707) 423-9463 · Call to confirm hours
Grocery
2525 N Texas St · (707) 421-2414 · Call to confirm hours
Park
3351 Hillridge Dr · (707) 428-7428 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.4%10.2%15.4%worse
Long-stay residents who lose too much weight1.8%4.0%5.4%better
Long-stay residents with a catheter left in their bladder2.7%0.8%0.9%worse
Long-stay residents with a urinary tract infection4.3%1.2%2.0%worse
Long-stay residents with depressive symptoms0.0%7.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.4%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.7%1.6%3.3%worse than state — see note marked double-dagger below the table
Long-stay residents on antianxiety or hypnotic medication24.6%13.7%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%98.2%95.3%typical
Long-stay residents with pressure ulcers3.4%4.3%4.7%better
Long-stay residents with worsening bladder/bowel control22.5%10.2%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table3.6%12.0%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%1.5%1.4%better
Short-stay residents given the seasonal flu vaccine96.6%93.2%79.4%better
Short-stay residents rehospitalized after admission18.0%23.0%22.6%better
Short-stay residents with an outpatient ER visit8.7%11.2%12.0%better
Long-stay hospitalizations per 1,000 resident days1.642.251.67typical
Long-stay outpatient ER visits per 1,000 resident days3.471.571.80worse

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

69.4% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 163 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

69.4%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
56.2%U.S. median 56.6%
Met the expected recovery
0.49U.S. median 0.31
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.18hours / resident / day
Occupational therapy
0.12hours / resident / day
Speech therapy

Met the expected recovery: 56.2% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 128 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 22% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF69.4%CMS range 64.0–75.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 8.6–15.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge56.2%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge41.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified89.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.7%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.8%CMS range 4.2–12.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.811.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.27
RN hours/ resident / day
0.87
LPN hours/ resident / day
2.98
Aide hours/ resident / day
5.12
Total nurse hours/ resident / day
0.85
RN hoursweekends
28.6%
Total nursing turnover
37.5%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 33.4 residents a day — about 56% occupied, or roughly 27 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.27 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.98 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.46 hrs/resident/day on weekends vs 5.39 on weekdays — 17% thinner on weekends. RN hours go from 1.44 to 0.85 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 29% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-04-17)
9
at the previous standard inspection (2025-02-14)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-04-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one out of two sampled resident (Resident 1) did not develop a pressure ulcer when the facility did not follow their policy and procedure for prevention of pressure injuries such as inspecting the skin daily when performing or assisting with personal care or activities of daily living (ADL, tasks of everyday life), did not continually evaluate Resident 1 ' s potential for skin breakdown per physician ' s order and request a preventative treatment prescribed by the physician once Resident 1 became incontinent of both bladder (the ability to control on when to empty the urine)and bowel function (the ability to control when to have a bowel movement). These failures resulted to Resident 1 acquiring a stage 2 pressure ulcer (PU, a shallow open ulcer with a red or pink wound bed, caused when an area of skin is placed under pressure ). Findings: A review of Resident 1 face sheet (demographics) indicated he was admitted on [DATE] with a diagnoses of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 39 when the controlled drug (a medication that may be abused or cause addiction) record form was not filled out and signed accurately. This failure has the potential to result in diversion of the residents' unused controlled medications.Findings:During an inspection of the Controlled Medication Disposition Log located in a secure locked cabinet at Station 1 on 4/15/26 at 10:25 a.m., the April 2026 Log had a total of five medication entries which coincided with the controlled medication in the bin within the cabinet. The April 2026 Log was missing the transferring licensed nurse's signature as well as the date the medications were removed from the medication carts to be stored in the secured locked cabinet before destruction.During an interview on 4/15/26 at 10:30 a.m. with the Director of Nursing (DON), the DON confirmed the Controlled Medication Disposition Log for April 2026 was missing the signature of the transferring licensed nurse and well as the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 4 sampled residents (Resident 23 and 39) for a census of 39.1. For Resident 23, a licensed nurse administered the wrong strength of eye drops, a medication to treat and prevent dry eye, per Physician Orders.2. For Resident 39, a licensed nurse did not educate and instruct the resident per manufacturer guidelines when administering a Metered Dose Inhaler (MDI), (a handheld, pressurized device used to treat breathing issues by delivering a specific amount of medicine directly into the airways). These failures resulted in 2 errors identified out of 34 opportunities for error during the observation of medication administration; the facility medication error rate was 5.88%. Findings:1. During an observation of medication administration on 4/14/26 at 9:05 a.m., Licensed Nurse (LN) 2 was observed preparing and administering Sodium Chloride Hypertonicity Ophthalmic (saltwater solution for the eyes) Solution, Brand name Muro 128 (an eye drops for dry eyes) 5%…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly labeled and stored in accordance with accepted standards of practice when:1. Multiple opened and undated multidose containers of glucose test strips (strips that can be used to measure blood sugar levels) were found in the medication carts, which had the potential to result in staff using expired, or ineffective glucose test strips to monitor residents blood glucose levels.2. Two over-the-counter eye drop bottles were found at Resident 55's bedside dresser.These failures may result in medications not being stored and maintained in a manner that will will ensure their safety, integrity and proper use placing the residents at risk for contamination, reduced effectiveness, and medication errors. Findings: 1. During an inspection of medication cart 2 located at nursing station 2 on [DATE] at 9:00 a.m. with Licensed Nurse (LN) 3, two open bottles of glucose test strips were found without an open…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 39 out of 39 residents when:1. Several various metal sheet pans and lids in clean and ready-to-use storage areas a. Were stacked wet while stored away b. Were dusty and oily2. Three large food storage bins had plastic containers for scoops inside the three food storage bins3. Pantry had four open milk cartons without an opened and use by dates written.4. Breakfast meal cart was left wide open, and unattended. These failures had potential to cause food borne illnesses in a highly susceptible population who received food from the kitchen. Findings: 1.During a concurrent observation and interview with Certified Dietary Manager (CDM) on 4/14/26 at 8:20 a.m., at the kitchen's initial tour, several metal sheet pans stored at the clean and ready-to use storage areas were observed stacked wet and were dusty and oily. The metal pans included: 5 full sheet table pans (wet) 6 full sheet covers/lid (dusty and oily) 1…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-04-17 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when:Resident 1's nasal cannula tubing was found on the floor,Resident 10 and Resident 56's oxygen tubing were on the floor, Resident 10's nebulizer mask was not stored in a bag, and Resident 56's nasal cannula was not stored in a bag,Resident 25's nebulizer mask was not stored in a bag,Resident 19's CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) mask was not stored in a bag, and;Resident 4's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing was on the floor and his CPAP mask was not stored in a bag.These failures had the potential to compromise resident's health and safety and potentially lead to the spread of communicable illnesses. Findings: 1.Review of a Detailed Summary (DS), Indicated Resident 1 was admitted February of 2026 with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-17 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents received appropriate meals/diets for 12 out of 39 sampled residents (Residents 3, 4, 16, 22, 23, 25, 26, 27, 28, 37, 39 and 43) when meal trays were being checked by unlicensed staff prior to delivery.This failure had the potential for residents on therapeutic diets to receive the wrong foods; residents with food sensitivities/allergies receiving inappropriate foods; and those on modified texture diets receiving inappropriate food items all of which could lead to complications and adverse reactions.Findings: During dining observation in the dining room on 4/16/26 at 11:55 a.m., observed Residents 3, 4, 16, 22, 23, 26, 27, 28, 37, 39 and 43 sitting at tables waiting for lunch to be served.During a concurrent observation and interview on 4/16/26 at 12:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 checked the meal trays prior to serving them to residents in the dining room. CNA 1 stated he was the only staff member that checked the meal trays and they were not checked before coming to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-14 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility had a 10.34% error rate when three medication errors out of 29 opportunities were observed during a medication pass for two of eight residents (Residents 4 and Resident 34). This failure resulted in medications not being given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions. Findings: 1a. During a review of Resident 4's physician order, dated 1/28/25, the order indicated, .[Metoclopramide HCl] [used to treat nausea and vomiting] - 5 mg (milligrams, a unit of measurement) *via G-tube [gastrostomy tube, a tube that provides access to the stomach]* 3 times a day for gastroparesis [a condition that affects the stomach muscles and prevent proper stomach emptying] . During a medication administration observation on 2/12/25 at 8:29 a.m., Licensed Nurse (LN) 1 administered five medications including Metoclopramide 5 mg by mouth. During a concurrent interview and record review on 2/12/25 at 11:19 a.m. with LN 1, LN 1 verified the order for Metoclopramide was to be given via…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-14 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure: 1. Expired and discontinued medications were not available for resident use; 2. Expired COVID-19 (a highly contagious respiratory disease caused by a virus) Test Kits were not available for resident use; 3. Opened single-use vial was discarded after use; 4. Medications were appropriately labeled with a pharmacy label or name to correctly identify which resident they were for; and, 5. Medication refrigerator was maintained in proper working condition. These failures had the potential for residents to receive medications with unsafe or reduced potency from being used past their expiration date or improper storage. Findings: 1. During a concurrent observation and interview on 2/11/25 at 10:49 a.m. with Licensed Nurse 3 (LN 3), an inspection of Station 2 Medication Storage Room identified the following expired and discontinued medications and medical supplies: - 28 Hydrogel absorbent sheet wound dressing (provide a moist environment for wounds to promote faster healing), expired 2/10/25; - Anasept gel…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-02-14 · tag F0803 — failed to meet residents' dietary needs — pattern
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) for lunch on 2/12/25 when four residents (Resident 4, 10, 16, 17) who were on Pureed (diet for people with trouble chewing, swallowing, or fully breaking down food and usually ground, pressed, or strained to pudding like consistency) received 1/4 cup serving of meat instead of 1/2 cup of meat as indicated on the menu. This failure had the potential to result in compromising the medical and nutrition status of the four residents. Findings: During an observation of lunch meal service on 2/12/25 beginning at 11:39 a.m., the following was observed: Residents 4, 10, 16, 17 who were on a pureed diet, received 1/4 cup of pureed chicken. A concurrent review of the facility spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. An ice machine was not clean; 2. Refrigerated food and a nutritional shake were not labeled with open, prepared, use by, or expiration dates; and, 3. The concentration of the sanitizer solution for a sanitation solution (red) bucket was less than 200 ppm. These failures had the potential to cause food-borne illness in a highly susceptible population of 31 of 31 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/11/25 at 8:16 a.m. with Director of Dietary Services (DDS), during the initial kitchen tour, an ice machine was observed to have dark stains resembling rust in a compartment directly next to ice bin, white matter on the exterior of the ice machine, and white debris in the ice scoop container. The DDS stated that an outside vendor is responsible for maintenance of the ice machine and the ice machine was serviced last week.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Ecited before2025-02-14 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 33 when: 1. Unlabeled and undated jug of distilled water used for CPAP (continuous positive airway pressure-a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) was observed on the floor at Resident 13's bedside; 2. Coffee mug was observed on a commode seat in Resident 31's bathroom; 3. Blood pressure (BP) cuff was not disinfected after use between residents (Resident 139, Resident 2, Resident 188, and Resident 4); 4. BP cuff and BP machine was not disinfected with appropriate disinfectant; 5. Dust particles were observed on the exhaust in the clean linen room in the laundry area; 6. Dirt and black stagnant water was observed on the drain at the back of washers in the laundry area; 7. Resident 4, who used a CPAP, had an opened and unlabeled bottle of distilled water on his nightstand; and 8.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-14 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 8), received sufficient fluids to maintain adequate hydration per resident's care plan and per Registered Dietician's assessment. This failure increased Resident 8's risk for dehydration (not enough fluids in the body to carry out normal functions) that can result in complication of the resident's medical conditions. Findings: A review of the Resident 8's admission records indicated the facility admitted the resident in 2024 with multiple diagnoses which included Parkinson's disease with dyskinesia (a progressive disease of the nervous system marked by involuntary shaking, muscular rigidity, and slow, imprecise movement of face, arms and legs), dementia (a progressive state of decline in mental abilities), and constipation (a problem with passing stool, caused by lack of fluids, dietary fiber, and exercises). A review of physician order for Resident 8 dated 12/3/24 indicated, Intake & Output [I&O] Record [the process of measuring and recording how much fluid…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-14 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35's routine dose of antidepressant was not discontinued after it was changed to PRN (as needed) and the PRN order did not have a specified end date. This failure had the potential to result in unnecessary medication for Resident 35, which had the potential for increased risk and exposure to side effects associated with psychotropic medications. Findings: During a review of Resident 35's admission record, the record indicated Resident 35 was admitted in January 2025 with diagnoses that included insomnia (trouble falling asleep or staying asleep) and depression (a condition characterized by persistent feelings of sadness, loss of interest, and low energy that interfere with daily life). Resident 35's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 35 had intact cognition.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-14 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure residents are free of any significant medication errors for one of 14 sampled residents (Resident 34) when Resident 34's Insulin Lispro (a fast-acting type of insulin - a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) was not administered with meals as ordered by the physician. This failure had the potential to result in the drop in Resident 34's blood sugar and the potential for Resident 34 to experience signs and symptoms of low blood sugar. Findings: During a review of Resident 34's admission records, the records indicated Resident 34 was admitted in January 2025 with diagnoses that included Type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Resident 34's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 34 had intact cognition. During a review of Resident 34's physician order, dated 2/1/25, the order indicated, Insulin lispro…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-02-14 · tag F0805 — failed to prepare food in a form residents can eat — isolated
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 16) received nectar thickened liquids as ordered by the physician, when Resident 16 was served thin liquids by Certified Nursing Assistant (CNA 2). This failure had the potential for Resident 16 to experience aspiration (accidental inhalation of food or fluids into the airways or lungs) and choking. Findings: During a review of Resident 16's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated, Resident 16 was admitted to the facility May 2024 with multiple diagnoses which included pneumonia (an infection/inflammation in the lungs). During a review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 12/4/24, the MDS indicated Resident 16 had difficulty swallowing and required a mechanically altered diet (change in texture of food or liquids). During a review of Resident 16's physician's orders, dated 9/17/24, the physician's orders indicated, .DIET…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-04-03 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure nursing staff were competent and had skills to provide nursing and related services to assure resident safety when the nurses did not follow the facility ' s policy and procedure on narcotic (drug that causes stupor or insensibility) count reconciliation (physical inventory of all controlled substances), when nurses left the medicine cart (med cart) keys on top of the med cart unattended and the nurses did not know Baza Cream (an incontinent cream that contains zinc oxide, a medicated cream, ointment or paste that treats or prevents skin irritation) requires a Physician Order (PO, the instruction the physician had written for a patients ' treatment ) prior to applying it on a resident skin. These failures were a safety risk that resulted in missing /unaccounted 3 tablets of narcotics (a medication that dulls the senses and treat pain) for one out of two sampled residents (Resident 2). These failures could lead to unauthorized access to the med…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-10 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that three of 12 sampled residents (Residents 23, 25, 141) had interdisciplinary (interventions from all departments) and comprehensive person-centered care plans that addressed their preferences (choices), goals (measurable expected outcomes) and interventions (care and services necessary to achieve those goals) when: 1) Resident 23 was on a Regular diet (one that does not include any dietary restrictions). A care plan for food preferences of broth, cheese & crackers, and pineapple to treat weight loss recommended by Registered Dietician (RD) was not developed, implemented and no interventions. 2) Resident 23 was taking Remeron (antidepressant) for depression (A mental health disorder characterized by persistently low mood or loss of interest in activities). A care plan was not developed which included the specific medications being used, the specific target behaviors for each medication, the expected goals to be achieved from…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0726 — failed to have competent, trained nursing staff — pattern
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure six Licensed Staff, which included one Physical Therapist had the appropriate skills and competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles) in providing care included but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs when: 1) A care plan was not developed and implemented for Resident 23, 25, 141 for special diet recommended by Registered Dietician (RD) and medications Remeron & Trazadone and oxygen administration. 2) A Licensed nurse did not clarify order with the Medical Doctor (MD) for medications called Remeron and Trazadone for Depression. Residents 23 & 25 did not have a Depression diagnosis documented. 3) A Doctor's order for oxygen was not clarified before administering Oxygen. The MD ordered continuous Oxygen, however, it did not have the amount of Oxygen to administer (for example, the number of liters of Oxygen). 4) A…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. A medication storage room was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 2. Expired medications were not removed and destroyed according to facility policy, with the potential for administration of expired and ineffective medications. 3. Medications requiring storage in the refrigerator were kept at a temperature higher than the recommended temperature range, with the potential for negative impact on effectiveness of the medications stored in the refrigerator. 4. Medications requiring storage at room temperature were kept in a medication room without monitoring the room temperature, a thermometer, or a temperature log with the potential for negative impact on potency of the stored medications. 5. A used inhaler and a bottle of sugar test strips were found in the medication cart without having the date opened and the new expiration date, with the potential for administration of expired medications or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-10 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and records review, the facility failed to implement measures to reduce the risk of disease and infection transmission, when: 1. The Certified Nursing Assistants (CNA) did not perform proper hand hygiene before and after assisting residents with meals and before and after passing individual food trays, for 12 out of 12 residents (Residents 2, 3, 5, 10, 11, 12, 14, 15, 22, 29, 34 and 38). This failure had the potential to result in spread of infections and/or transmission of diseases to the staff and vulnerable residents. 2. The facility failed to ensure staff were not wearing gloves while feeding a resident (Resident 11). This failure had the potential for an issue with resident dignity and/or increased infection transmission. 3. The facility failed to ensure the Freestyle Libre 2 reader (a continuous glucose monitoring reader) for Resident 14 was adequately sanitized when staff used a sanitizing wipe that was not recommended by the manufacturer. These failures had the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to ensure they had developed a baseline care plan for one out of seven sampled residents (Resident 240) within the first 48 hours of admission which should have provided instructions for the provision of effective and person-centered care for Resident 240. This failure could adversely affect the resident's health and safety. Findings: A review of Resident 240's face sheet (demographics) indicated Resident 240 was [AGE] years old, admitted to the facility on [DATE]. Her diagnoses included Esophageal Obstruction (a deformity in which the esophagus, a hollow, muscular tube that passes food and liquid from your throat to your stomach, was partially or completely blocked), Cachexia (Loss of body weight and muscle mass, and weakness that may occur in patients with chronic diseases) and Hypertension (high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure). Resident 240 received her nutrition via a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-10 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when Expired E-Kits (Emergency-Kit, storage box containing emergency supplies of medication) medications were not removed and replaced according to facility policy, with the potential for administration of expired and ineffective emergency medications or having medication errors. Findings: During a concurrent observation of medication room's refrigerator (station 2) and interview with Licensed Staff Q (LS Q) on 3/6/23 at 10:45 a.m., three medication E-Kits were found in the refrigerator which expired on 7/31/21, 7/31/21, and 1/4/23. LS Q confirmed all E-kits in the refrigerator were expired and needed to be replaced by the pharmacy. During an interview with the Director of Nursing (DON) on 3/9/23 at 9:05 a.m., the DON acknowledged that expired E-Kits should have been removed by the staff. The DON further stated that E-kits were also discontinued. The DON confirmed that having discontinued and expired medications available to staff could increase the risk of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and records review, the facility failed to: 1. act on the facility's Consultant Pharmacist's (CP) recommendation for one of three residents (Resident 15) when the physician, the Director of Nursing (DON), and new CP did not follow-through the recommendation to gradually reduce the dose of escitalopram (medication for depression - a mood disorder that causes a persistent feeling of sadness and loss of interest affecting how you feel, think and behave and can lead to a variety of emotional and physical problems) with the addition of buspirone (medication for anxiety - a mental disorder in which a person is often worried or anxious about many things and finds it hard to control this anxiety). This failure had the potential to increase the risk of a rare but serious condition characterized by confusion, hallucination (hearing, seeing, feeling, smelling, or even tasting things that seem real, but they're not), seizure, extreme changes in blood pressure, increased heart rate, fever, excessive…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-03-10 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% (percent) for three sampled residents (Resident 142, Resident 190, and Resident 8) when: 1. For Resident 142, a licensed staff did not administer Resident's oxybutin (a medication for overactive bladder), as ordered by the physician. 2. For Resident 190, a licensed staff did not administer Resident's fish oil (a medication for heart health), as ordered by the physician. 3a. For Resident 8, a licensed staff did not administer Resident 8's fish oil as ordered by the physician. 3b. For Resident 3, a licensed staff did not administer Resident 8's glucosamine (a medication for joint health) as ordered by the physician. These failures resulted in four errors identified out of 34 opportunities during the observation of medication administration; the facility medication error rate was 11.76 %. Findings: 1. During an observation of medication administration on 3/6/23 at 10:45 a.m., Licensed Staff Q (LS Q) prepared and administered Resident 142's medications which did…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · tag F0895 — isolated
    Have a Compliance and Ethics Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to implement their compliance and ethics policy when a medication temperature monitoring log was falsified with a potential to negatively impact the quality of pharmaceutical products being stored in a medication storage room or a medication refrigerator. Findings: During a concurrent inspection of station 1's medication refrigerator and interview with Licensed Staff R (LS R) on 3/7/23 at 9:40 a.m., the temperature of the refrigerator, in which vaccines were stored, was observed to be at 50 degrees F (Fahrenheit, unit of measure for temperature). LS R acknowledged that the temperature in the refrigerator was out of range (36-46 F). LS R also confirmed that the temperature log was not being completed by the facility and the log was not completed for at least 4 consecutive days in March (3/2/23, 3/3/23, 3/4/23, 3/5/23) in the morning and in the evening. During a concurrent inspection of station 1's medication refrigerator and interview with LS A on 3/8/23 at 11:30 a.m., the temperature of the refrigerator was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-10 · tag F0919 — failed to provide a working call system — isolated
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance from staff) for one out of five sampled residents (Resident 36) was working as indicated by the funtioning of the red light above Resident 36's door. This failure could result in residents not being able to call staff for assistance which had the potential to result in late provision of care, care not rendered, or accidents and falls. Findings: A review of Resident 36 face sheet (demographics) indicated Resident 36 was initially admitted to the facility on [DATE]. Resident 36's diagnoses included Bilateral Hearing Loss (hearing loss on both ears), Hypertension (high or raised blood pressure, a condition in which the blood vessels have persistently raised pressure) and Polyneuropathy (when multiple peripheral nerves become damaged, symptoms includes problems with sensation, coordination, or other body functions). Her Minimum Data Sheet assessment (MDS,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$35,493 in federal fines across 1 penalty.

  • $35,493 — penalty dated 2024-04-03

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
WHITLEY, TERESAIndividualCONTRACTED MANAGING EMPLOYEEsince 02/01/2017
DE LEON, JENNIFERIndividualW-2 MANAGING EMPLOYEEsince 02/23/2022
DODDS, SHANNONIndividualW-2 MANAGING EMPLOYEEsince 02/23/2022
HOGAN, KEVINIndividualW-2 MANAGING EMPLOYEEsince 02/12/2024
ANDERSON, ANDREAIndividualCORPORATE DIRECTORsince 05/25/2023
ASPLING, DEBORAHIndividualCORPORATE DIRECTORsince 01/18/2018
BOWERS, ROBERTIndividualCORPORATE DIRECTORsince 01/18/2018
DIMICHELE, JOHNIndividualCORPORATE DIRECTORsince 03/16/2017
EPPERSON, ROBERTIndividualCORPORATE DIRECTORsince 09/28/2023
ERICKSON, GARYIndividualCORPORATE DIRECTORsince 01/08/2014
GRIPMAN, SARAIndividualCORPORATE DIRECTORsince 09/28/2023
KURKJIAN, THOMASIndividualCORPORATE DIRECTORsince 07/13/1998
LEVIN, EDWARDIndividualCORPORATE DIRECTORsince 05/25/2023
MULTANI, JASBIRIndividualCORPORATE DIRECTORsince 05/25/2023
QUINN, SEANIndividualCORPORATE DIRECTORsince 11/12/2015
SCHMIDT-BERRINGER, SANDRAIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/19/2015
WIEDEMAN, GEOFFREYIndividualCORPORATE DIRECTORsince 06/01/2016
YANG, PINGIndividualCORPORATE DIRECTORsince 05/25/2023
BURKE, KEVINIndividualCORPORATE OFFICERsince 06/19/2017
NORTHERN CALIFORNIA RETIRED OFFICERS COMMUNITYOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 07/13/1998

CMS files one row per role, so the 21 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$34.0M
Net patient revenuemost recent cost report
-47.2%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 0%Medicare 30%Other / private 70%

A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

What families pay in CA

Paying with Medicaid

CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the California Medicaid page for homes that do.

Typical monthly cost in California
$12,167/mo
Nursing home (semi-private)
$15,178/mo
Nursing home (private)
$7,000/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555727. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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